Healthy Kids Extended Day Program
2014-2015 Registration Packet
New York City, Peekskill, Poughkeepsie City and Yonkers Schools
Admin offices: 565 Union Avenue New Windsor, NY 12553
www.HealthyKidsProgram.org
Welcome to the Healthy Kids Extended Day
Program. We understand that child care is one of
your most important decisions and we’re glad that
you have chosen the Healthy Kids Program to meet
your childcare needs.
We’re here to help you in any way. If you need any information or have any
questions, just e-mail us or call us at 845 568 6100.
The Healthy Kids Before/After School program is one of the largest, most
experienced and highest quality providers of extended day child care in New York with
programs in dozens of elementary schools in Brooklyn, Dutchess, Orange, and Westchester
counties. Our directors and staff are highly skilled, background-checked and credentialed.
NYS Office of Children and Family Services licenses and oversees our programs. We
gladly accept DSS and ACS.
First, let me introduce our team.
•
For programs in NYC or Westchester County, e-mail Vicki Luongo, Regional
Director at Vicki@HealthyKidsProgram.org or call (845) 568-6100 ext 1001
or (914) 361-4160
•
For programs in Dutchess or Orange Counties, e-mail RaeAnne Nocera,
Regional Director at RaeAnne@HealthyKidsProgram.org or call (845) 5686100 ext 1004 or (914) 361-4160
•
Jeanne Martin is the Registration Director & DSS Specialist, e-mail
Jeanne@CommunityFitnessCenter.com or call (845) 568-6100 ext 1002
Sincerely yours,
The Healthy Kids Extended Day Program Team
P.S. Register before August 15th and pay nothing until the Wednesday before the first
week of the program.
1
For help with this application, contact Jeanne Martin at Jeanne@CommunityFitnessCenter.com
or call Jeanne at (845) 568 -6100 ext 1002
Healthy Kids Extended Day Program
2014-2015 Registration Packet
New York City, Peekskill, Poughkeepsie City and Yonkers Schools
Admin offices: 565 Union Avenue New Windsor, NY 12553
www.HealthyKidsProgram.org
This application is for the programs at the following locations:
NEW YORK CITY PROGRAMS
BROOKLYN SCHOOLS
PS 75, Brooklyn
After school until 6pm
After school until 6pm
PS 185, Brooklyn
PS 446, Brooklyn
After school until 6pm
DUTCHESS COUNTY PROGRAMS
POUGHKEEPSIE CITY SCHOOL DISTRICT
Pre-k & Kindergarten:
AM Program: 8:10AM- 12:05PM
PM Program: 11:10AM- 3:00PM
WW Smith ELC
After school until 6pm
WESTCHESTER COUNTY PROGRAMS
PEEKSKILL SCHOOL DISTRICT
Before school as early as 7am
Woodside
Oakside
Hillcrest
After school until 6pm
After school until 6pm
After school until 6pm
YONKERS SCHOOL DISTRICT
After school until 6pm
Cornell Academy
Cross Hill Academy
Dichiaro School
Montessori 27
Pulaski Elementary School
School 21
After school until 6pm
After school until 6pm
After school until 6pm
After school until 6pm
After school until 6pm
Summary of Fees, See pages 6 and 7 for more fee details
After school fees, until 6pm
After school
fees
(until 6pm)
5 days/week
4 days/week
3 days/week
2 days/week
1 day/week
After
School
Fees
(Siblings
save 10%)
$90/week
$75/week
$60/week
$50/week
$35/week
After School
Fees for families
qualifying
for reduced
lunch
$75/week
$65/week
$55/week
$45/week
$30/week
Fees for
families
qualifying
for free
lunch
$60/week
$55/week
$45/week
$35/week
$30/week
Please see
pages 6
and 7 for
pre-k fees
2
For help with this application, contact Jeanne Martin at Jeanne@CommunityFitnessCenter.com
or call Jeanne at (845) 568 -6100 ext 1002
Healthy Kids Extended Day Program
2014-2015 Registration Packet
New York City, Peekskill, Poughkeepsie City and Yonkers Schools
Admin offices: 565 Union Avenue New Windsor, NY 12553
www.HealthyKidsProgram.org
GENERAL INFORMATION
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Healthy Kids Extended Day Programs offers 1, 2, 3, 4 and 5 day a week options.
There are reduced fees for families qualifying for free or reduced lunch.
Children eligible to participate in the Healthy Kids Extended Day Program must be
registered in elementary school or a pre-k program.
The fees are collected on a bi-weekly basis and are averaged out for all the
scheduled school days.* Consequently, the bi-weekly rate is the SAME whether
there are 10 school days in the upcoming two weeks or fewer school days.
Collection days INCLUDE school days off and the two week periods including
Winter and Spring break. For more info on fees see page 7.
*The Healthy Kids rate per day is $21.00. The weekly tuition is $90.00, which breaks down to $18.00/per day to
average out for the days that the program is not in session (ie Winter Recess, Spring Break, etc.).
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•
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•
•
Prior to beginning any Healthy Kids Program, all children are required to have a
complete application on file including their medical history.
All Pre K students must also provide immunization records.
The program follows the schools district calendar and will not run on any days that
the school is closed unless otherwise noted.
Healthy Kids is unable to provide supervision of students whose personal needs are
greater than regulated staffing ratios allow.
If your school district makes the decision to dismiss school early (early dismissal)
due to snow or other unscheduled event, the Healthy Kids After School program
will be cancelled. If your school district has a delayed opening, the Healthy Kids
Before School program is cancelled.
Please call the public school phone number and listen to recording for closing
updates or check the district’s website. Healthy Kids will not make calls to inform
you of any last minute emergency school closings.
The Healthy Kids Extended Day Program operates under a license from the NYS
OCFS which oversees and regulates childcare programs. Among the requirements
of the license is a full background check of all staff (including fingerprinting).
We gladly accept DSS and ACS. Our Westchester DSS vendor # id is 147960. Our
Dutchess DSS vendor # id is SAC66763. Contact us for the ACS number.
PARENT HANDBOOK
You’ll find lots more information in the parent handbook. You can find a printable version
of the Parent Handbook on our website, www.healthykidsprogram.org and you will receive a
copy via e-mail as part of your registration confirmation correspondence.
3
For help with this application, contact Jeanne Martin at Jeanne@CommunityFitnessCenter.com
or call Jeanne at (845) 568 -6100 ext 1002
Healthy Kids Extended Day Program
2014-2015 Registration Packet
New York City, Peekskill, Poughkeepsie City and Yonkers Schools
Admin offices: 565 Union Avenue New Windsor, NY 12553
www.HealthyKidsProgram.org
We ask all parents to go over this code of conduct with enrolled
children. We place a high importance on all students treating others in
a positive, respectful way. We follow a progressive discipline philosophy
and will bring the parent in early in the process.
•
•
•
•
•
•
•
Healthy Kids Extended Day Program Code of Conduct
We will always place safety first; which will mean regular buddy checks, safety
drills and procedures to ensure child safety. Safety procedures are to be treated
with utmost importance.
Children are expected to be respectful, honest and kind. Use positive language, be
gracious competitors, show good sports etiquette and share
Be considerate to others and to the environment by cleaning up after yourselves.
In a group situation, please no talking while someone else is speaking, always raise
your hand if you have something to contribute and use inside voices indoors.
Follow your program staff’s directions, if you do not understand, ask questions!!!
No violence, throwing things, rough housing, profanity or demeaning language.
Always engage a program staff person to settle an issue between students. Don’t
take matters into your own hands.
•
•
•
Consequences of not following code of conduct
The Director will determine disciplinary action after staff reports incidents.
Consequences may include (1) a gentle reminder (2) a few minutes aside from
group activity (3) call guardian and leave for the day (4) child will be removed
from the program with no refund.
Healthy Kids Extended Day Program reserves the right to immediately dismiss
any child from the program for extremely disruptive behavior, for behavior
placing a student/staff safety in jeopardy or any violence. Examples include but
are not limited to: (1) intentionally hurting another child (2) stealing (3) refusing
to comply with a safety directive (4) violence, etc.
We have zero tolerance for violence and believe that there are no reasons or
circumstances that call for violence. We require children to bring issues to staff
person’s attention for help in solving them before it escalates to violence. Any
child who harms another will be expelled, WITH NO REFUND of tuition. This
includes pushing, biting, and kicking, etc.
4
For help with this application, contact Jeanne Martin at Jeanne@CommunityFitnessCenter.com
or call Jeanne at (845) 568 -6100 ext 1002
Healthy Kids Extended Day Program
2014-2015 Registration Packet
New York City, Peekskill, Poughkeepsie City and Yonkers Schools
Admin offices: 565 Union Avenue New Windsor, NY 12553
www.HealthyKidsProgram.org
We take child safety very seriously and use our rules and a code of
conduct to help make sure your child is as safe as absolutely possible.
EXTENDED DAY PROGRAM RULES AND REGULATIONS
•
•
•
•
•
•
•
•
•
•
All parents/guardians must follow proper sign in and sign out procedures. We
cannot overstate how important this is. If child (ren) is leaving with an approved
person but someone other than their parent/guardian, photo identification must be
presented.
Children cannot attend program if they have a fever or contagious illness.
Parents will be notified, and children must be picked up in the event of illness.
We use the Rule of Three when the program is running. All children must be
accompanied by TWO other individuals including a staff person. No exceptions.
Children must stay with group/leader at all times and must participate in the Rule
of Three when using the restroom.
Appropriate attire must be worn at all times. Please label all children’s items.
Lunch will be provided daily for pre-k students and healthy snacks will be provided
daily for after school children.
Please leave all electronic devices at home. The only exception is cell phones which
are to remain in the child’s book-bags and are only to be used for emergency
communication with parent/guardian.
Please note there are no refunds or credits given for days not attended, or for
cancelled enrollment without proper notification.
Attendance is specific to days of enrollment. There is no “switching days” or
“making up days” due to a holiday, school cancellation, illness, or parent work
schedule.
5
For help with this application, contact Jeanne Martin at Jeanne@CommunityFitnessCenter.com
or call Jeanne at (845) 568 -6100 ext 1002
Healthy Kids Extended Day Program
2014-2015 Registration Packet
New York City, Peekskill, Poughkeepsie City and Yonkers Schools
Admin offices: 565 Union Avenue New Windsor, NY 12553
www.HealthyKidsProgram.org
PRE-K & KINDERGARTEN WRAPAROUND FEE INFORMATION
Pre-k Fees
Pre-k Fees for families
Pre-k Fees for families
(Siblings save 10%)
qualifying for reduced lunch
qualifying for free lunch
5 days/week
$110/week
$90/week
$70/week
4 days/week
$95/week
$80/week
$65/week
3 days/week
$80/week
$70/week
$55/week
2 days/week
$60/week
$50/week
$45/week
1 day/week
$40/week
$35/week
$30/week
These fees also apply to the half day kindergarten program at WW Smith
Pre-k Fees
BEFORE SCHOOL INFORMATION
Before School Program
7AM
Drop off
Before School Fees7AM Drop off
(Siblings save 10%)
Before School Fees for
families qualifying
for reduced lunch
Before School Fees for
families qualifying
for free lunch
5 days/week
4 days/week
3 days/week
2 days/week
1 day/week
$60/week
$50/week
$40/week
$30/week
$20/week
$50/week
$40/week
$35/week
$25/week
$15/week
$40/week
$35/week
$30/week
$20/week
$15/week
8AM
Drop off
Before School Fees8AM Drop off
(Siblings save 10%)
Before School Fees for
families qualifying
for reduced lunch
Before School Fees for
families qualifying
for free lunch
5 days/week
4 days/week
3 days/week
2 days/week
1 day/week
$45/week
$40/week
$35/week
$30/week
$20/week
$40/week
$35/week
$30/week
$25/week
$20/week
$35/week
$30/week
$25/week
$20/week
$15/week
AFTER SCHOOL FEE INFORMATION
After
School Fees
After School Fees
(Siblings save 10%)
5 days/week
4 days/week
3 days/week
2 days/week
1 day/week
$90/week
$75/week
$60/week
$50/week
$35/week
After School Fees for
families qualifying for
reduced lunch
$75/week
$65/week
$55/week
$45/week
$30/week
After School Fees for
families qualifying
for free lunch
$60/week
$55/week
$45/week
$35/week
$30/week
Pre-payment plan: save 10%
Pay your entire pre-k or after school tuition in full by August 15th 2014 and take 10% off
your total tuition PLUS pay no registration fee. Pay in full after August 15th 2014 take
10% off your total tuition and pay a $25 registration fee.
6
For help with this application, contact Jeanne Martin at Jeanne@CommunityFitnessCenter.com
or call Jeanne at (845) 568 -6100 ext 1002
Healthy Kids Extended Day Program
2014-2015 Registration Packet
New York City, Peekskill, Poughkeepsie City and Yonkers Schools
Admin offices: 565 Union Avenue New Windsor, NY 12553
www.HealthyKidsProgram.org
KEY INFORMATION ABOUT TUITION AND PAYMENTS
1) For all programs there is an annual registration fee:
If you enroll in the automatic payment program, the registration fee is waived as long as you
enroll by August 15th 2014; it is $25/child if you enroll after August 15th, 2014.
There is a $100/family cap on registration fees, regardless of the number of children.
2) Discounts:
Take a 10% off REGULAR rates for enrolling in any two programs including before school,
after school, pre-k wraparound or kindergarten wraparound.
Sibling discount: first child pays regular rates, all siblings get take 10 % off regular rates.
No discounts off of reduced rates
Pre-payment plan: save 10%. Pay your entire before/after school tuition in full by August
15th 2014 and take 10% off your total tuition plus pay no registration fee. Pay in full
after August 15th save 10% off your total tuition but pay a $25 reg fee.
3) Automatic payments.
Fees shown are for automatic withdrawal from a checking account. A $5/payment
surcharge is added for automatic payment with a credit card.
Fees are deducted bi-weekly, prior to the week’s start. Student cannot attend program
without payment. Fees will be pro-rated to reflect actual start date
4) Fees are collected every two weeks prior to attendance and on the following dates:
Please note: your first payment may be pro-rated based on your school’s start date.
August 27
September 10 & 24
October 8 & 22
November 5 & 19
December 3 & 17 & 30
January 14 & 28
February 11 & 25
March 11 & 25
April 8 & 22
May 6 & 20
June 3 & 17 (pro-rated for remaining days)
5) Checks/debits that are returned are charged a $15 fee per occurrence.
6) Proof is required to qualify for reduced rates. You can contact your district’s Food Service
Office to obtain a letter from them. Please include a copy in your registration packet.
7) The fees are collected on a bi-weekly basis and are averaged out for all the scheduled
school days.* Consequently, the bi-weekly rate is the SAME whether there are 10
school days in the upcoming two weeks or fewer school days. Collection days INCLUDE
school days off and the two week periods including Winter and Spring break. For more
info on fees see page 7.
*The Healthy Kids rate per day is $21.00. The weekly tuition is $90.00, which breaks down to $18.00/per day to
average out for the days that the program is not in session (ie Winter Recess, Spring Break, etc.).
8) There are no refunds or credits for days missed, snow days or days that the school district
cancels our program.
9) Attendance is specific to days of enrollment. There is no “switching days” or “making up days”
due to a holiday, school cancellation, illness, or parent work schedule.
10) We gladly accept DSS. Our Westchester DSS vendor # is 147960. Our Dutchess DSS vendor
# is SAC66763. Please contact us for the ACS number.
7
For help with this application, contact Jeanne Martin at Jeanne@CommunityFitnessCenter.com
or call Jeanne at (845) 568 -6100 ext 1002
Healthy Kids Extended Day Program
2014-2015 Registration Packet
New York City, Peekskill, Poughkeepsie City and Yonkers Schools
Admin offices: 565 Union Avenue New Windsor, NY 12553
www.HealthyKidsProgram.org
REGISTRATION
A. Tell us about the child(ren) you are enrolling
1. Children’s Name____________________________________ Age on 9/2_________
Date of Birth____________ Gender (M or F) Grade_______________
School_________________________ Program Start Date___________
Program Site_____________________
2. Children’s Name______________________________________Age on 9/2________
Date of Birth____________ Gender (M or F) Grade ________________
School ________________________ Program Start Date____________
Program Site______________________
3. Children’s Name____________________________________ Age on 9/2__________
Date of Birth____________ Gender (M or F) Grade _________________
School__________________________ Program Start Date___________
Program Site______________________
B. Tell us about you and how to contact you.
Parent/Guardian Name _____________________________________________________
Address ___________________________City________________State_____Zip_________
Tel. Numbers Home__________________Work___________________________________
Cell number______________Email___________________________________
Emergency contact
Name________________________ Phone__________________
Name________________________ Phone__________________
C.
Let us know if it’s ok to use photos of your child in marketing material.
I grant permission to use photographs of my child taken at the Healthy Kids program for publicity
purposes PLEASE INITIAL HERE ________.
8
For help with this application, contact Jeanne Martin at Jeanne@CommunityFitnessCenter.com
or call Jeanne at (845) 568 -6100 ext 1002
Healthy Kids Extended Day Program
2014-2015 Registration Packet
New York City, Peekskill, Poughkeepsie City and Yonkers Schools
Admin offices: 565 Union Avenue New Windsor, NY 12553
www.HealthyKidsProgram.org
D. Who you authorize to pick up your child (ren). Please note we will not release
your child to anyone not listed below. Also, if the person who is authorized to
pick your child up is not a parent/guardian we will ask for a photo id before
releasing your child.
1.
Name
_________________________________ Phone___________________
Relationship to child
2. Name
_________________________________ Phone___________________
Relationship to child
3. Name
______________________________________________
______________________________________________
_________________________________ Phone___________________
Relationship to child ______________________________________________
E. Let us know that you agree with our (1) rules and regulations (2) code of
conduct and (3) progressive discipline action plan.
I _____________ (parent/guardian name) have read the (1) rules & regulations (2) code of
conduct and (3) progressive discipline action plan and agree with them.
PLEASE INITIAL HERE ________.
I, for myself and anyone entitled to act on my behalf, waive and release the Healthy Kids Program
and its representatives from all claims and liabilities of any kind arising out of participation in this
program or related activities. PLEASE SIGN HERE _________________ _______
Parent/Guardian’s Signature Date
I _________________________________(child(ren)’s name(s)) understand that hitting, using
rude language or being mean to others is not allowed in the Healthy Kids Before/After School
Program. I understand if I do any of those my parent (s) will be called and I could be expelled.
___________________________________________________
_______________
Child (ren)’s signature(s)
Date
While homework is an important element of our program, our main focus in on child development.
We allow a maximum of 60 minutes for homework each day.. If you would like a lower homework
limit for your child, just let us know below.
• My child will NOT do homework while attending the Healthy Kids Extended Day Program.
PLEASE INITIAL HERE ________.
• My child will do homework for a maximum of _____ minutes per day Monday- Thursday.
PLEASE INITIAL HERE ________.
9
For help with this application, contact Jeanne Martin at Jeanne@CommunityFitnessCenter.com
or call Jeanne at (845) 568 -6100 ext 1002
Healthy Kids Extended Day Program
2014-2015 Registration Packet
New York City, Peekskill, Poughkeepsie City and Yonkers Schools
Admin offices: 565 Union Avenue New Windsor, NY 12553
www.HealthyKidsProgram.org
F. Although medical situations are rare and those that do occur are most often
solved with a band aid we need to be prepared for any and every possible
contingency.
MEDICAL AUTHORIZATION
In the event of serious illness or injury, I authorize the Healthy Kids Program Staff to obtain
necessary emergency medical treatment. Every attempt to contact a parent or guardian will be
made. I accept responsibility for the cost involved in the transport and treatment of my child.
Child (ren)’s Name (s) ________________________________________________________
Hospital insurance carrier______________________________
Child’s Physician_________________________________________________
Phone____________________________ Address__________________________
Child’s Dentist________________________________________________________
Phone____________________________ Address__________________________
If guardian cannot be reached, list contact numbers to be used:
#1
Name: _________________________ Relationship to Child___________________
Home Tel.__________________________ Cell ______________________________
Alternate Tel.________________________________
#2
Name: _________________________ Relationship to Child___________________
Home Tel.__________________________ Cell _______________________________
Alternate Tel._______________________________
I, _________________________ (parent/guardian name) have read, understand, and agree with
all of the above.
PLEASE SIGN HERE _______________________
____________
Parent/Guardian’s Signature
Date
10
For help with this application, contact Jeanne Martin at Jeanne@CommunityFitnessCenter.com
or call Jeanne at (845) 568 -6100 ext 1002
Healthy Kids Extended Day Program
2014-2015 Registration Packet
New York City, Peekskill, Poughkeepsie City and Yonkers Schools
Admin offices: 565 Union Avenue New Windsor, NY 12553
www.HealthyKidsProgram.org
Medical History
A separate form must be completed for each child.
Please note: immunizations and a Doctor-signed physical is required for following schools:
W.W. Smith ELC
Child’s Name_____________________________________
1.
Date
________________
Has your child been under any medical care within the last year? If yes, why?
______________________________________________________________________
2. Is your child on any medication? Y or N. If yes, what is the name of the medication(s) _____ _
Note: ANY CHILD ATTENDING THE PROGRAM WITH EPI PENS OR INHALERS MUST
HAVE PRE-APPROVED PERSONAL HEALTH CARE PLAN
3. Is your child allergic to penicillin or any other drugs? Y or N If yes, please list___________
4. Does your child wear any appliances? (Glasses braces, etc.)___________________________
5. Are there any current conditions that the staff should be aware of? ___________________
_______________________________________________________________________
6. Is your child subject to any of the following? (check all that apply)
_____fainting spells
_____headaches
_____tonsillitis
_____eczema
_____stomach upset
_____wetting
_____abdominal pains
_____hay fever
_____convulsions
_____diabetes
_____sinus trouble
_____frequent sore throat
_____asthma
_____bronchitis
_____ear infections
_____constipation
_____mood disorders
_____other, please list______
7. Does your child suffer from:
_____lung problems
_____kidney problems _____heart problems
_____hernia
_____epilepsy
_____allergic reaction to bee stings
_____other allergies, explain_______________________________________________
8. Can we administer over the counter ointment like polysporin on your child if necessary? Y or N
8. Please note we are not authorized to administer any medications. The exceptions are epi-pens
and inhalers with a pre-approved personal health plan.
PLEASE SIGN HERE _______________________
Parent/Guardian’s Signature
____________
Date
11
For help with this application, contact Jeanne Martin at Jeanne@CommunityFitnessCenter.com
or call Jeanne at (845) 568 -6100 ext 1002
Healthy Kids Extended Day Program
2014-2015 Registration Packet
New York City, Peekskill, Poughkeepsie City and Yonkers Schools
Admin offices: 565 Union Avenue New Windsor, NY 12553
www.HealthyKidsProgram.org
First Aid Kit - Child Information Summary – Page 1
We keep this form in the first aid kit at the extended day location it has a
summary of all your child’s important information. We strongly recommend
including a photo in the top left hand corner.
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
DAY CARE REGISTRATION
Child’s Full Name:
PHOTO OF CHILD
(Optional)
Does your child have any allergies?
If Yes, what is your child allergic to?
Yes
No
Children who have special health care needs are those who have chronic physical, developmental,
behavioral or emotional conditions expected to last 12 months or more and who also require health and
related services of a type beyond that required by children generally. If your child does have special health
care needs please discuss these with your child-care provider.
Child’s Source of Medical Care/Primary Care Physician’s Name:
Telephone Number:
Child’s Source of Dental Care/Dentist’s Name:
Telephone Number:
Name Of Medical Care Facility/Hospital:
Telephone Number:
Would you like information on Child Health Plus?
CONTACT NAME
No
TELEPHONE NUMBER DURING CHILD CARE
OTHER TELEPHONE NUMBER (Check type)
EMERGENCY DATA
RELATIONSHIP
Yes
Pager
Cell
Other
Pager
Cell
Other
Pager
Cell
Other
Pager
Cell
Other
OCFS-LDSS-0792 (1/2005) FRONT
12
For help with this application, contact Jeanne Martin at Jeanne@CommunityFitnessCenter.com
or call Jeanne at (845) 568 -6100 ext 1002
Healthy Kids Extended Day Program
2014-2015 Registration Packet
New York City, Peekskill, Poughkeepsie City and Yonkers Schools
Admin offices: 565 Union Avenue New Windsor, NY 12553
www.HealthyKidsProgram.org
First Aid Kit - Child Information Summary – Page 2
CHILD’S FULL NAME:
SEX:
Male
Female
DATE OF BIRTH:
CHILD’S HOME ADDRESS:
DATE OF ACCEPTANCE:
DATE OF DISCHARGE:
NAME OF PERSON APPLYING FOR CHILD:
Parent
Guardian HOME TELEPHONE NUMBER:
Caretaker
Relative
DAYTIME TELEPHONE NUMBER:
Other
Location:
ADDRESS OF PERSON LISTED ABOVE: (IF DIFFERENT FROM CHILD’S):
Healthy Kids Extended Day Program
Provider/Day Care Facility Name and Address:
HOME TELEPHONE NUMBER:
AGREEMENTS
I consent to the enrollment of the child listed above in this facility and have been advised of the policies regarding administration of
medications, fees, transportation and the services provided by the facility, and the Office of Children and Family Services regulations
under which it operates.
I give consent for my child to take part in neighborhood trips (i.e. library, park and playground) away from the facility under proper
supervision.
Yes
No
In case of accident or injury, I authorize any and all emergency medical, dental, and /or surgical care and hospitalization advised
by the physicians, surgeon or hospital (listed on the other side of this card) necessary for the proper health and well-being of my
child.
Yes
No
I have provided information on my child’s special needs (Allergies, Diet, Disabilities, and /or Medical Information) to the provider,
as may be necessary to assist the facility in properly caring for my child in case of an emergency.
Yes
No
I agree to review and update this information whenever a change occurs and at least once every six months.
SIGNATURE – PARENT OR PERSON(S) LEGALLY
RESPONSIBLE
DATE:
OCFS-LDSS-0792 (1/2005) REVERSE
13
For help with this application, contact Jeanne Martin at Jeanne@CommunityFitnessCenter.com
or call Jeanne at (845) 568 -6100 ext 1002
Yes
No
Healthy Kids Extended Day Program
2014-2015 Registration Packet
New York City, Peekskill, Poughkeepsie City and Yonkers Schools
Admin offices: 565 Union Avenue New Windsor, NY 12553
www.HealthyKidsProgram.org
Payment Worksheet
Child (ren)’s name ________________________________________________
Parent/guardian name _________________________
Tel Number_________
School __________________Before/After School Program Site____________
Part One: Registration Fee
Please check your payment method for monthly tuition and date of registration
Automatic tuition payment and registering by August 15th, 2014 reg fee = waived
Automatic tuition payment and registering after August 15th 2014 reg fee =
$25/child
Pay tuition with check, cash or credit card and registering by August 15th 2014 reg
fee = $25/child
Pay tuition with check, cash or credit card and registering after August 15th 2014
reg fee = $75/child
Line A: Registration fee per child =
___________
Line B: Registration fee x number of children (150/family cap) = __________
Please note:
•
•
•
•
If you have any questions about the automatic payment plan, e-mail Lorie at
Lorie@CommunityFitnessCenter.com
If at any time you switch from automatic payment plan to NON-automatic payment plan you
must pay the difference in registration fees from what you paid at the beginning and the
prevailing rate.
Pre-payment plan: save 10%. Pay your entire before/after school tuition in full by August
15th and take 10% off your total tuition plus pay no registration fee. Pay in full after
August 15th save 10% off your total tuition but pay a $25 reg fee.
The fees are collected on a bi-weekly basis and are averaged out for all the
scheduled school days.* Consequently, the bi-weekly rate is the SAME whether
there are 10 school days in the upcoming two weeks or fewer school days.
Collection days INCLUDE school days off and the two week periods including
Winter and Spring break. For more info on fees see page 7.
*The Healthy Kids rate per day is $21.00. The weekly tuition is $90.00, which breaks down to $18.00/per day to
average out for the days that the program is not in session (ie Winter Recess, Spring Break, etc.).
14
For help with this application, contact Jeanne Martin at Jeanne@CommunityFitnessCenter.com
or call Jeanne at (845) 568 -6100 ext 1002
Healthy Kids Extended Day Program
2014-2015 Registration Packet
New York City, Peekskill, Poughkeepsie City and Yonkers Schools
Admin offices: 565 Union Avenue New Windsor, NY 12553
www.HealthyKidsProgram.org
Part two: tuition
First Child’s Name____________________________________
Pre-k Program (and Kindergarten program at WW Smith)
o Pre-k/K location: (fill in) ________________ (see page 2 for location list)
pm program
o Select program – (circle one) am program
o
Select days: (circle days) Mon Tues Wed Thurs Fri
Pre-k/K Tuition
_________________
Before School Program – Woodside Only
o Select days: (circle days) Mon Tues Wed Thurs Fri
o Select 7AM or 8AM Drop off
Before School Tuition
_________________
After-school Program:
o After school location: (fill in) ________________(see page 2 for location list)
o
o
Select days: (circle days) Mon Tues Wed Thurs Fri
After School Tuition
__________________
First child’s tuition:
Line C: Total Pre-k/K, before and/or after school tuition
=
_________
Line D: 10% discount for any TWO programs (Pre K & After school, OR
Before & After school
-_________
Discount off regular rates only, no discount off reduced rates
Line E: $5.00 surcharge if you elect to pay automatically by credit card
instead of electronically through checking-
Line F: First child discounted sub-total (lines C - D + E = F)
=
+_________
__________
Proof required to qualify for reduced rates
15
For help with this application, contact Jeanne Martin at Jeanne@CommunityFitnessCenter.com
or call Jeanne at (845) 568 -6100 ext 1002
Healthy Kids Extended Day Program
2014-2015 Registration Packet
New York City, Peekskill, Poughkeepsie City and Yonkers Schools
Admin offices: 565 Union Avenue New Windsor, NY 12553
www.HealthyKidsProgram.org
Sibling Name_________________________ (Use a separate sheets for each sibling)
Pre-k Program (and Kindergarten program at WW Smith)
o Pre-k/K location: (fill in) ________________ (see page 2 for location list)
o Select program – (circle one) am program
pm program
Select days: (circle days) Mon Tues Wed Thurs Fri
o
o
Pre-k/K Tuition
_________________
Before School Program – Woodside Only
o Select days: (circle days) Mon Tues Wed Thurs Fri
o Select 7AM or 8AM Drop off
o
Before School Tuition
After-school Program:
o After school location:
o
_________________
(fill in) ________________(see page 2 for location list)
Select days: (circle days) Mon Tues Wed Thurs Fri
After School Tuition
__________________
Sibling tuition:
Line G: Pre-k/K, before and/or after school tuition for sibling
=
Line H: 10% discount for any TWO programs (Pre K & After school, OR
Before & After school
_________
-_________
Discount off regular rates only, no discount off reduced rates
Line I: 10% discount for sibling discount
- _________
Discount off regular rates only, no discount off reduced rates
Line J: Sibling discounted sub-total (lines G-H-I = J)
=
__________
Proof required to qualify for reduced rates
16
For help with this application, contact Jeanne Martin at Jeanne@CommunityFitnessCenter.com
or call Jeanne at (845) 568 -6100 ext 1002
Healthy Kids Extended Day Program
2014-2015 Registration Packet
New York City, Peekskill, Poughkeepsie City and Yonkers Schools
Admin offices: 565 Union Avenue New Windsor, NY 12553
www.HealthyKidsProgram.org
Automatic Payment Authorization Form:
To
Registration
Staff:
____________________________________________________________________________
Authorization Agreement for Direct Payments (ACH Debits)
Please
forward this
___________________________________________________________________________
form to
E-mail address
Day Phone
Lorie.
Make sure to
___________________________________________________________________________
attach a
Child/Children’s Name
voided check
Parent/Guardian Last Name
First
________________________________
Extended Day Program School Site
_______________________________
Weekly Debited Amount
I (we) hereby authorize Healthy Kids Extended Day Program, hereinafter called COMPANY, to initiate
debit entries to my (our) _____ Checking Account/ _____Savings Account (select one) indicated below at
the depository financial institution named below, hereafter called DEPOSITORY, and to debit the same to
such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must
comply with the provisions of U.S. law.
For those choosing automatic payment through checking/savings account:
Please attach voided check to this form
Please check here if your checking account is already on file and unchanged. If so, there is no
need to give us your banking info or voided check.
Depository name________________________
City_______________________________-__
Routing number________________________
Branch _____________________________
State________ Zip _____________________
Account number ________________________
For those choosing automatic payment through a credit card:
Name on credit card_______________________________________ Type of card___________
Billing address_________________________________________________________________
Card number_____________________________ Expiration Date___________Security code_____
This authorization is to remain in full force and effect while your child is enrolled in the 2014-15
Before/After School program until COMPANY has received written notification from me (or either of us) 3
weeks in advance of its termination in such time and in such manner as to afford COMPANY and
depository a reasonable opportunity to act on it. Please submit written notification of any termination or
changes to Lorie Coombs at Healthy Kids Extended Day Program, 565 Union Avenue, New Windsor, NY
12553 or e-mail to Lorie@CommunityFitnessCenter.com
_____________________________
______________________________ _______________
Name(s) (please print)
Signature
Date
NOTE: DEBIT AUTHORIZATION MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION
ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.
17
For help with this application, contact Jeanne Martin at Jeanne@CommunityFitnessCenter.com
or call Jeanne at (845) 568 -6100 ext 1002